Evidence‐based review: Screening body dysmorphic disorder in aesthetic clinical settings

Body dysmorphic disorder (BDD) is a psychiatric disturbance with high incidence in aesthetic clinical settings. Early recognition may avoid unnecessary elective procedures with ethical and medicolegal consequences.


| INTRODUC TI ON
Body dysmorphic disorder (BDD) represents a psychiatric disturbance characterized by a disproportionate preoccupation with a perceived or minor defect in the appearance imperceptible to others. 1 According to the Diagnostic and Statistical Manual of Mental Disorder (DSM-5) criteria, BDD is classified under obsessivecompulsive disorders and distinct from eating disorders (Figure 1). 1 The estimated prevalence in general population ranges from 0.7% to 2.9%. [2][3][4] The BDD prevalence varies, depending on the population and criteria adopted, but it is thought to be higher among patients seeking for aesthetic treatments and predominantly in the face. 5,6 Gender ratio is reportedly equal, although some studies found a slight preponderance in women, highlighting the need for larger epidemiological studies in BDD prevalence. 5,7 The excessive concern is deemed pathological, and leading to compulsive appearance-focused K E Y W O R D S aesthetics, body dysmorphic disorder, evidence-based review, screening F I G U R E 1 Body dysmorphic disorder definition. DSM-5 criteria. Taken from American Psychiatric Association. 1 behaviors with negative impact on occupational and social interactions. 1 Ultimately, BDD expressing major distress and/or functional impairment may extend to anxiety, depression, self-harm behaviors, or even suicide. 1,8 The suicidality risk is estimated to be 4-2.6 times higher than general population, regarding suicidal ideation and suicide attempts, respectively. 8 Preliminary studies have shown that patients diagnosed with BDD usually exhibit unsatisfactory outcomes or symptoms aggravation following aesthetic treatment. 9,10 A recent survey reported that 88% of BDD patients became more aware of the perceived defect, and 76% found new concerns. 9 This seems to be in line with current research demonstrating that nearly 98% of the individuals suffering from BDD had no benefit from elective interventions, with perceived worsening of their image at 16%. 10,11 These statistics explain why many practitioners have been reluctant to perform aesthetic treatments on patients believed to have BDD, which has been generally recognized as a contraindication for elective treatments. Although this has been controversial, with one systematic review showing lack of high-quality studies to support the current hypothesis, 12 there is consensus regarding the importance of screening BDD prior to aesthetic interventions, and to re-assess afterward for any emergent psychological conditions. 13 Failure to do so can result in adverse consequences to both patients and practitioners. 5 Alarmingly, there have been reports of threats with legal action and violence among BDD patients toward plastic surgeons, with few cases culminating in murder. 14,15 Thus, recognizing the signs of BDD and identifying vulnerable prospective patients is crucial, considering that the appropriate management involves a referral to a psychiatrist approach rather than aesthetic intervention. 6 Interestingly, one study in Saudi Arabia suggested that cultural differences rendered lack of management of confirmed BDD involving psychiatrists, considering that in the country a patient diagnosed with BDD may be stigmatized. 16 Moreover, studies have emphasized the challenge of establishing BDD diagnosis or recognizing high-risk patients during a preoperative consultation, leading to an increased risk of unnecessary elective procedures with ethical and medicolegal consequences. 13,17 It may be particularly difficult for aesthetic practitioners without training or experience in mental health to determine if the appearance-preoccupation is disproportionate when the defect is only mild, fueling the debate on whether BDD incidence in aesthetic population may be underrated. 3,5 Indeed, the survey provided by Joseph et al., 10 demonstrated that from a sample of 402 participants, 42 patients screened positive on a BDD questionnaire, 16 were clinically suspected of having BDD, while only two were appropriately identified by aesthetic surgeons. Another recent observational cross-sectional study by Kattan et al., 16 exploring 155 aesthetic practitioner's awareness of BDD concluded that more familiarity with BDD diagnostic criteria resulted in an increased number of appropriate identification of cases.
In this context, the aim of this evidence-based review was to identify validated BDD screening tools and appraise available data regarding its implementation and efficacy in daily practice, by preventing post-treatment complications for both aesthetic patients and practitioners. Previous reviews on this topic have not sought to clearly distinguish the validated screening tools for BDD from nonvalidated instruments or other measures for BDD that have been misused for screening purposes in the aesthetic population. 2,3,[18][19][20] Therefore, the present study attempted to address this gap in the available literature, and to assess the impact of current discrepant interpretations of screening measures for BDD on reported validation processes of screening instruments, and aesthetic treatment outcome among positive screening patients.

| ME THODOLOGY
A best evidence topic (BestBETs) methodology for a systematic approach to summarize literature evidence was conducted. 21 This methodology has been previously fully described in published data and considered a suitable format to identify and appraise evidence on relevant clinical topics in which there are limited studies available and with great heterogeneity; hence, the study outcomes are likely not suitable for meta-analysis. 22 Following a literature search and outcome report, a BestBETs  (Table S1). 23 The studies retrieved were categorized as: I-systematic review of randomized trials (RCTs); II-individual RCTs; III-systematic review of non-randomized controlled cohort/ follow-up study (or individual studies); IV-systematic review of case series, case-control studies, or historically controlled studies (or individual studies); and V-mechanism-based reasoning/expert opinion. Study quality and inconsistencies were used to up/down grade the evidence level. The author's quality classification of their own study or included studies was accepted and no attempts to reclassify them were made. To evaluate the detailed methodology of the different study types, the adapted BETs critical appraisal checklist was used (Table S2). 21 The data extracted and appraised for each study was confirmed by reviewer consensus. The study quality classification was performed independently by the reviewers, and any disagreement was resolved through an open discussion.

| S E ARCH S TR ATEGY-OUTCOME
The search was conducted on PubMed (MEDLINE). Publications were limited to human studies, from inception up to August 2022. To ensure a comprehensive search, further publications were obtained by hand-search of references of the relevant papers. Unpublished papers, conference material, case reports, or articles with full text inaccessible were excluded. The primary studies already evaluated in the included systematic reviews were also excluded. The study quality classification was only provided for studies in aesthetic population using validated BDD screening tools or developing new screening measures for BDD. The studies referring to BDD subtypes or validating non-English versions of BDD screening tools were excluded. The key search terms and eligibility criteria for studies inclusion and exclusion are provided in the adapted PRISMA diagram ( Figure 2). 24 Data extracted included authors name and year of publication, type of aesthetic intervention, BDD screening tools used, its validity, sensitivity, and specificity, as well as major findings such as the correlation between a positive screening and outcome following treatment, study characteristics and weaknesses with assigned level of evidence (LOE) (Table S1).

| RE SULTS
The initial search yielded 179 articles, of which 12 were retrieved for analysis as per the selection criteria shown in Figure 2 Table 1. This includes the BDD screening tools used in patients seeking specific aesthetic treatments, the original authors, existent translated versions, as well as each screening tool validity, sensitivity, specificity, and predicting value for postoperative outcomes. Table 2  items: "concerns about physical appearance is this mainly related to weight and preoccupation by these concerns" and in any of the questions related to the "effect of preoccupation on daily life" and reports of DCQ alone is not sufficient to diagnose BDD. It intends to measure the severity of dysmorphic concern helping to identify patients at risk. 50 4. BDD (Self-Report) Questionnaire Aesthetic Surgery Aesthetic rhinoplasty surgery Demonstrated to have 81.4% specificity and 89.6% sensitivity in the aesthetic rhinoplasty setting. 51 No validated diagnostic tool for BDD was used in the validation process. Convergent validity was assessed by comparing the BDDQ-AS to the SDS and DAS. To assess its concurrent validity, BDDQ-AS was compared to BDD-YBOCS. 52 The positive/negative predictive value was 76 Original validation process has limitations.
All language versions of the COPS questionnaire showed sufficient internal consistency and reliability Screening tools validated in aesthetic population: BDDQ, BDDQ-DV, DCQ BDDQ-AS and COPS -validation process with limitations.
SI-BDD -validated process with inconsistencies and unpublished * Included in Table 2 Impact of positive screening on outcome following aesthetic procedures: BDDQ -two studies found no influence of positive screening on postoperative satisfaction (rhinoplasty population). 27

TA B L E 1 (Continued)
TA B L E 2 BDD-related reported screening tools excluded with reasons.

Studies Intervention Characteristics
Diagnostic tool 6. BDD (Clinician) Examination (BDDE)**: consists of a 34-item clinical interview, of which 29 items pertain to body-image attitudes. A 7-point scale rates the severity/frequency. At least 2 items relate to assessors rating of the subject physical appearance and if the presenting concern is disproportional or not. Other items include the patient explanation of the physical appearance concern(s) with/without other somatic issues and history of aesthetic treatments for that purpose 2  Most widely used in research to measure BDD severity. 3,18 Intended for use only after confirmed diagnosis of BDD. Clinical interview-based described as reliable, reproductible, and valid severity measure tool. 68 (also reportedly being used to screen BDD). 3 Requires a trained clinician or mental health professional. The Self-report version lack reliability and validity demonstration

Non-validated screening tools in aesthetic population:
Screening tools reported in published literature without available data on sensitivity and specificity for BDD screening.  Table S1.

| Study characteristics and quality
From the 12 relevant articles produced using aforementioned research strategy, five were systematic reviews related to aesthetic interventions, 2,3,18-20 which referenced a total of 27 prospective non-randomized follow-up studies , 10 for BDD using a modified version of COPS in cosmetic dermatology practice, which was also graded level V due to methodological limitations. 13 Overall, the seven studies involved a total of 1765 participants with sample sizes ranging from 76 to 734. Among the primary studies included, only the cross-sectional online survey by Pikoos retrospectively evaluated the aesthetic minimally invasive treatment outcomes for patients who screened positive for BDD against those who did not. 84 These findings reflect in part the quality of the data analyzed. Full key characteristics of included studies are available in Table S1. The domains of adapted BETs critical appraisal worksheets used with an assessment for each study are illustrated in Table S2.

| DISCUSS ION
Body dysmorphic disorder involves a distorted perception of physical appearance, hence the thought that elective procedures rarely achieve the desired outcomes currently prevails. 50 There are clear pragmatic advantages for the early detection of BDD patients seeking aesthetic interventions for the wrong reasons and with unrealistic expectations. 4 Published data highlighted that any suspected cases of BDD would benefit from a multidisciplinary approach, whereby a referral to mental health professionals for timely management and risk-benefit analysis has been recommended. 2,6 However, there are currently no clinical guidelines for the correct screening of BDD. 5 In fact, studies have shown that timely identification of patients at risk of BDD is either commonly missed or ineffective. 51  critical. This is particularly true considering that BDD patients tend to hide any practical signs that may preclude elective procedures. 13

| Validated BDD screening tools
There are a few BDD-specific screening tools to be used at the time of initial assessment described in the literature, although no single self-report questionnaire or rating scale has been universally accepted. 2 In line with previous reviews, the present study also concluded that considering the high prevalence of  44 reported that the appropriate cut-off value of DCQ was ≥11 or ≥15 to screen for BDD or estimate its prevalence, respectively. Conversely, Mancuso et al., 45 Woolley and Perry, 47 Metcalfe et al., 48 and Pérez Rodríguez et al., 49

| Efficacy of BDD screening tools
The systematic review by Picavet et al. 2  were significantly less satisfied with the results. However, the sample size was small, and while the positive predicted value was estimated 76.8%, the BDD-positives were not interviewed by a clinician to confirm the diagnosis. It seems therefore that the more recent studies using validated BDD screening tools were supportive of a relationship between BDD-positive screenings and poor subjective outcomes following rhinoplasty and oculofacial plastic aesthetic surgery. Interestingly, only the two prospective studies using other non-validated measures to screen BDD have investigated the subjective outcomes following non-surgical minimally invasive treatments. 13,84 The positive screenings for the multiphasic approach by Fletcher using the modified version of COPS have been reportedly successfully treated. 13

| Limitations
The present review is not free from limitations. Firstly, it is not a rigorous systematic review including unpublished or gray literature and the search was conducted using limited databases. Thus, some evidence on the topic may have been missed. Secondly, by excluding the studies already evaluated in the systematic reviews from individual analysis, or by accepting the studies own judgment of quality and risk of bias assessment, there is the risk of overgeneralisation of results (e.g., it has been predicted that the LOE for all the studies included in the systematic reviews was not higher than level III, and that Spataro et al. cohort self-classification provided the highest level II evidence). Contributing further to this issue, the inclusion criteria was broad and not specific for an aesthetic intervention (e.g., BDD screening tools may be more or less effective depending on the type of procedure being temporary or permanent, subtle or more visible). There was little representation of non-surgical procedures, commonly dealing with minor defects. Given that BDD is often associated with an obsession over small imperfections, further well-designed studies using validated screening tools in this field may be able to amplify the results. Finally, the great heterogeneity of results (e.g., primary and secondary care settings, or dental vs. plastic surgery-based work) and lack of high-quality studies available prevented a more meaningful statistical analysis.

| CON CLUS ION
Not without controversy, there is an ever-growing acceptance that BDD is a contraindication for undergoing aesthetic interventions or at the very least a combined mental health professional assessment is recommended for definitive diagnosis and input into decisionmaking processes. This is in line with the desirable patient-centered and holistic approach. The mental health assessment aims to evaluate the suitability for treatment, to reduce incidence of complications, while providing psychological support to those in need. 18 However, the lack of knowledge of the available screening methods or concerns regarding tests reliability, alongside underestimation of BDD prevalence and/or misunderstanding of the implications of treating such patients may be behind the low routine screening.
Other barriers that have been reported include the lack of staff to implement the screening which can be time-consuming, pressures from a competitive market and risk to lose prospective patients. 13 While the screening for this disorder enables the recognition of the individuals at risk and promotes good patient care, the best screening tool for the wide-ranging aesthetic clinical settings is yet to be including patients seeking to improve moderate acne which arguably have non-existent or minor defects imperceptible to others). An evaluation based on high-quality studies is needed to provide standardized protocols for research and clinical practice. Future studies may elucidate which BDD characteristics/specific factors best predict a favorable outcome. It would be helpful to identify and assess BDD positive screenings outcomes and desire for re-interventions with validated screening tools and PROMs, as well as to provide long-term follow-up of their psychological well-being, particularly in patients undergoing non-surgical aesthetic treatments with temporary effects, requiring continuous interventions by nature, and often provided by non-medical professionals.

AUTH O R CO NTR I B UTI O N S
All authors contributed to data collection, data analysis, and critical revisions of the article. All authors read and approved the final version of the submitted article.

ACK N OWLED G M ENT
The authors thank Mrs Reem Al-Barazanchi for her assistance in proofreading this review.

FU N D I N G I N FO R M ATI O N
This study received no funding.

CO N FLI C T O F I NTE R E S T S TATE M E NT
All the authors declare that they have no conflict of interest in this study.

DATA AVA I L A B I L I T Y S TAT E M E N T
Data sharing not applicable to this article as no datasets were generated or analysed during the current study.

E TH I C A L A PPROVA L
The authors confirm that the ethical policies of the journal, as noted on the journal´s author guidelines page, have been adhered to. No ethical approval was required as this is a review article with no original research data.